Ghostbusters

Hillary’s health-care plan

A spectre is haunting the leading candidate for the Democratic Presidential nomination. It was with her last week when she outlined her health-care proposal, and it was no wispy phantom. It was an apparition solid enough to attract the notice of political reporters inured to paranormal phenomena by long months on the campaign trail.

DES MOINES, Sept. 17—Senator Hillary Rodham Clinton unveiled a plan on Monday to guarantee health insurance to all Americans, but in a way carefully designed to avoid the political flaws in her failed proposal of 1993-94.

That’s how the Times led its Tuesday story from Iowa. But whether the collapse of the most ambitious domestic policy initiative of the (Bill) Clinton Administration is a horrid fiend, red of eye and gnarled of hand, or more of a winsome Friendly Ghost, like Casper, depends on one’s point of view. Senator Clinton, naturally, is of the Casper school. In her Des Moines speech, she said she had “learned some valuable lessons that have shaped how I approach health-care reform today.” Her opponents for the nomination, naturally, would prefer that voters see her experience as something more apt to be repeated than learned from. “The cost of failure fourteen years ago isn’t anybody’s scars or political fortune,” John Edwards said. “It’s the millions of Americans who have now gone without health care for more than fourteen years.” And Barack Obama said, “The real key to passing any health care reform is the ability to bring people together in an open, transparent process that builds a broad consensus for change.”

What this kind of (still relatively civilized) political jousting should not be allowed to obscure is that—within the Democratic Party, at least—a broad consensus for change has already emerged. Clinton’s proposal comes nearly eight months after Edwards’s and four months after Obama’s, but all three are remarkably similar, and those of Edwards and Clinton nearly identical. She and her staff used the extra time to advantage: her program is the most expertly packaged and tidiest of the three, and manages to sound at once nonthreatening and far-reaching. If you like the health plan you’ve already got—and, gee, who doesn’t?—you keep it. If you don’t like it, or if you’re uninsured, you can choose from the same menu of private plans offered to members of Congress. Or you can opt for a new public plan modelled on Medicare. You can’t be blackballed or socked with unaffordable premiums on account of having a “preëxisting condition.” You can buy a gold-plated executive policy if you wish, but you’ll have to pay the difference yourself, with post-tax dollars. Whatever you choose, you have to take it upon yourself to choose something—the “individual mandate” that policy wonks talk about. It’s like having to get car insurance. Clinton estimates the cost of all this at a hundred and ten billion dollars a year—a third of the annual bill for Medicare. The bulk of it would come from letting the Bush tax cuts on incomes over a quarter of a million dollars expire on schedule.

There’s a lot more detail, of course. And by the time the Clinton plan—or the Edwards plan or the Obama plan—got fed through the congressional wood chipper, it would probably make Rube Goldberg’s craziest invention look like the Lever of Archimedes. But it would do two important things. First, it would end the disgrace of America’s being the only advanced capitalist democracy on earth that does not guarantee health care to its citizens. Second, with any luck, it would create a slow-motion showdown between private and public health insurance. Given that private insurers spend around fifteen per cent of their budgets on administration—much of it devoted to keeping the sick off the rolls and, failing that, figuring out ways to avoid paying their medical bills—while Medicare spends two per cent, it ought to be an interesting and instructive contest.

The Clintons blew it last time, but they weren’t the first to break their picks against the unyielding granite of the American political system. Every Democratic President since Truman has been elected on a platform of national health insurance, and, in spite of public support for the idea by majorities as big as those in Europe, every one of them has failed to get it enacted. In this country, elections are just the beginning. To get to the finish line, a big reform has to run a gantlet of three independently elected “governments”—not just the Presidency but also the House and the Senate, all the members of which are elected independently of one another, too. Besides all this, the committees of Congress, where most business actually gets done, provide plenty of dark corners where determined, well-financed, well-organized special interests can make short work of an obvious but amorphous majority will.

We’ve been here before, but this time the stars may really be coming into alignment. Our health-care system has continued to deteriorate. We spend twice as much as the French and the Germans and two and a half times as much as the Brits, yet we die sooner and our babies die in greater numbers. Thirty-eight million Americans were uninsured in 2000; now it’s forty-seven million. Employer-based health insurance is increasingly expensive, stingy, and iffy. Companies, especially manufacturing companies, are beginning to realize that being deputized to pay the health-care costs of their employees and retirees puts them at a competitive disadvantage in the global economy.

Whether change comes will depend entirely on the next election. If a Democrat wins the Presidency after outlining his or her intentions as specifically as the leading contenders have done, and if the Democrats substantially increase their congressional majorities, then it will happen. If they don’t, it won’t.

“People have access to health care in America,” President Bush remarked last summer, expressing the view of many conservative Republicans. “After all, you just go to an emergency room.” And, last Thursday, for what he called “philosophical” reasons, he promised to veto an expansion of the State Children’s Health Insurance Program, a modest federal effort to help states cover children from poor and near-poor families. The Republicans who hope to succeed him offer conservative think-tank homilies about the glories of the market. Last week, Mitt Romney denounced Clinton’s proposal—and, by extension, those of Edwards and Obama (to say nothing of the plan which he himself negotiated with the Democratic legislature when he was governor of Massachusetts, and which contains most of the same elements)—as “a European-style socialized-medicine plan.” This rhetorical zombie, though, isn’t as scary as it used to be. Americans already have some experience with European-style socialized-medicine plans. The two most efficient, merciful, and politically unchallengeable components of the American health-care system—Medicare and the Veterans Administration—closely resemble what the French and the British, respectively, provide to all their citizens. No need to get spooked. ♦

Hendrik Hertzberg is a senior editor and staff writer at The New Yorker. He regularly blogs about politics.